A clinically useful conceptualization of emotion regulation grounded in functional contextualism and evolutionary theory
Authors: Kim L. Gratz, Matthew T. Tull
Journal: World Psychiatry (2022)

Perhaps nothing is more central to the human experience than emotions. How individuals experience and respond to their emotions has been linked to psychological and physical health and overall well-being1. In particular, emotion regulation has been identified as one of the most critical factors contributing to psychopathology and adaptive functioning alike2. Despite its clinical importance, conceptualizations of emotion regulation vary greatly. Although some of this variability can be explained by whether the conceptualization focuses on the regulation of emotions at the micro or macro level (with micro level approaches focusing on the specific strategies that people use to influence their emotions, and macro level approaches focusing on the typical ways in which individuals understand and respond to their emotions3), some appears to be driven by differences in how emotions and their role in functioning are conceptualized and understood. Specifically, if emotions (particularly negative emotions) are viewed as potentially disruptive to the pursuit of goals and/or in need of control or modification, then conceptualizations of emotion regulation may emphasize the down-regulation of negative emotions, enhancement or sustainment of positive emotions, and/or modification of the experience or expression of emotions in some way. On the other hand, if the understanding of emotions is grounded in evolutionary theory on the functionality of emotions and their utility in guiding behaviors and valued actions4-6, then a relevant conceptualization of emotion regulation would emphasize adaptive responses to emotions that facilitate their functional use as information to guide behavior (vs. modification of emotions as the goal). It is this latter approach to the conceptualization of emotion regulation that we recommend as most clinically useful for guiding assessment and intervention. This approach is best exemplified by the acceptance-based mod­el of emotion regulation6, which conceptualizes emotion regulation as adaptive ways of responding to emotions, including the understanding, acceptance, and effective use and modulation of emotions7. According to this model, adaptive responses to emotions are those that facilitate the functional use of emotions as information and the pursuit of valued actions, whereas maladaptive responses are those that interfere with accessing, using, or learning from the information provided by emotions. Thus, the acceptance and understanding of emotions are considered the foundational abilities that are necessary for adaptive emotion regulation. Moreover, although the effective modulation of emotions is considered one aspect of adaptive emotion regulation within this model, it is not necessary for adaptive regulation to occur; instead, identifying and labeling emotions and being willing to experience emotions are theorized to be regulating in their own right. Likewise, although specific modulation strategies are not considered inherently adaptive or maladaptive within this model (as the effectiveness of any strategy can only be evaluated in the context of the individual's goals and situational demands), strategies that facilitate access to the information provided by emotions and application of that information in a functional way are considered more adaptive than strategies that interfere with understanding emotions and the information they provide. Thus, key to determining the adaptiveness of any given strategy in the moment is understanding the function or purpose of that strategy, with strategies that aim to avoid emotions considered less adaptive than acceptance- or approach-based strategies. Finally, the foundational abilities identified in this model are expected to affect the selection and use of modulation strategies by interacting with the situation to influence the individual's goals. For example, individuals who respond to their emotions with acceptance and a desire to understand and learn from them would generally be expected to choose emotion modulation strategies that do not interfere with accessing or using the information provided by emotions (e.g., talking about their emotions with others, journaling, self-soothing). On the other hand, individuals who negatively evaluate or disregard their emotions may be more likely to choose avoidance strategies that interfere with the functional use of emotions regardless of the context. Notably, by not suggesting that emotions must be modified, this conceptualization of emotion regulation is consistent with the burgeoning literature on acceptance-based interventions that emphasizes the utility of emotions and the benefits of experiential acceptance7, 8. Further, by focusing on adaptive responses to emotions rather than the nature or quality of those emotions, this conceptualization separates emotion regulation from the experience of emotions, proposing that intense, reactive or labile emotions are not inherently dysregulated, and even individuals with a temperamental emotional vulnerability can be emotionally regulated (as long as they respond to their emotions in adaptive ways). Indeed, according to this model, how someone responds to an intense or reactive emotion plays a key role in the trajectory, duration and consequences of that emotion (consistent with research suggesting that responses to emotions are more relevant to mental and physical health than an individual's emotional temperament9). Given the substantial impact of emotion regulation on numerous aspects of functioning and health2, the systematic and reliable assessment of this construct in clinical settings is imperative for effective clinical decision-making. One of the most widely used and extensively supported self-report measures is the 36-item Difficulties in Emotion Regulation Scale (DERS)6, which is based on the acceptance-based conceptualization of emotion regulation discussed here. In addition to providing a total score of overall emotion regulation difficulties, this measure provides scores for six subscales assessing difficulties in the key emotion regulation abilities of: emotional acceptance; emotional awareness; emotional clarity; access to effective emotion modulation strategies; controlling impulsive behaviors when distressed; and engaging in goal-directed behaviors when distressed. Not only are scores on the DERS significantly associated with numerous clinically relevant behaviors (e.g., self-injury, binge eating, substance use) and psychiatric disorders (e.g., borderline personality disorder, anxiety disorders, post-traumatic stress disorder, eating disorders), but extensive research also demonstrates that the DERS is sensitive to change following psychological treatments and can be used to track progress in emotion regulation over the course of treatment9. Moreover, although its self-report format increases its feasibility and ease of administration, the DERS is significantly associated with behavioral, neurological and physiological measures of emotion regulation9. Beyond established self-report measures such as the DERS, cli­nicians can use behavioral techniques such as functional analysis to assess individuals' responses to their emotions, including their acceptance and understanding of these emotions, how these emotions inform their behaviors (effectively or ineffectively), and the immediate and long-term emotional, cognitive, behavioral and interpersonal consequences of these responses. Repeated functional analyses with a patient may also increase insight into the functions of and motives for the selection and use of particular modulation strategies across different contexts, as well as highlight instances of emotion regulation inflexibility that can be targeted in treatment. Although the term "emotion regulation" can imply that emotions require or need modification or modulation, we propose that the modulation of emotions is only one aspect of adaptive emotion regulation, and that effective emotion modulation requires emotional acceptance and understanding. In contrast, a singular emphasis on the modification or modulation of emotions obscures the fact that emotions serve important and necessary functions.